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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803815
Report Date: 02/20/2025
Date Signed: 02/20/2025 02:13:31 PM

Document Has Been Signed on 02/20/2025 02:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AMERICAN ASSISTED LIVINGFACILITY NUMBER:
486803815
ADMINISTRATOR/
DIRECTOR:		SUKHJIT SANDHUFACILITY TYPE:
740
ADDRESS:405 KINGS WAYTELEPHONE:
(510) 604-3825
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 30CENSUS: 22DATE:
02/20/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Sukhjit Sandhu, licensee/administratorTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On 02/20/25 Licensing Program Analyst (LPA) Star Stevenson and licensing Program Manager (LPM) Kim Mota arrived unannounced at approximately 9:45 AM to conduct a concurrent visit with Suisun City fire Marshall Jose Colin.
At approximately 09:55AM a walk through of the facility bedrooms, kitchen, bathrooms, garage and exterior were performed with LPA, LPM and Fire Marshall Jose Colin.
Four (4) electrical cover-plates were observed to be missing in room one(1), room six(6), living room and above fire suppression system in garage. (Pictures taken)

During walk-through/observation of rooms five(5), six(6), fourteen(14) and fifteen(15) had a strong smell of urine.
At 9:50AM room seven(7) was noted to have a table and folding chair blocking the exterior door/fire exit.(picture taken)

At 10:54AM It was observed that part of a hospital bed was blocking the exterior exit ramp from room eight(8) (picture taken)

During walk-through/observation, Patio/Sunroom did not have audible wander alarm on exterior doors.

Room one(1) and three(3) were observed to have trash cans with incontinence debris with no lids.(photos taken)
LPAs observed room three(3) is missing a window screen (photos taken)

At approximately 11:00AM licensee/administrator Sukhjit Sandhu arrived. An interview with Staff (S1) stated they had not participated in a disaster drill for approximately one year. In addition licensee/administrator was unable to provide documentation of thee emergency disaster drills.
Continued on LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 02/20/2025 02:13 PM - It Cannot Be Edited


Created By: Star Stevenson On 02/20/2025 at 11:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2025
Section Cited
CCR
87202(a)

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87202(a) Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city... fire department... providing fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
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Staff immediately moved the table and chair away from door. Licensee to submit Self-Certification stating that training will be conducted with all staff and that Regulation 87202 Fire Clearance will be reviewed with all staff.
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Based on LPAs& Fire Marshall observation, the Licensee did not comply with the section cited above. LPA observed exit obstructed by tray table in Bedroom #7. Facility immediately moved items. This poses an immediate health, safety or personal rights risk to persons in care.
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Self Certification to be submitted to Community Care Licensing by POC due date of 02/21/2025, and Training log signed by all attending staff to be submitted by due date of 02/28/2025.
Civil penalties in the amount of $1,000.00 is being assess due to repeat violations in the past 12 months.
Type A
02/21/2025
Section Cited
CCR87303(a)

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87303(a) Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on observations, the licensee did not comply with the section cited above:
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Licensee to ensure facility is maintained in a clean and safe manner. Licensee will make repairs, clean and disinfect areas, repair electrical cover plates, replace missing screen in room 3 and repair window in room 3.
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The following areas of disrepair were observed: holes in walls, missing switch plate covers, urine odor, trash cans without lids, general lack of cleanliness, immediate health, safety or personal rights risk to persons in care.
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 Licensee to provide LPA pictures and a plan for continuous upkeep by 02/21/2025......Civil penalties in the amount of $250.00 is being assessed due to repeat violations in the past 12 months for regulation 87303(a) previously cited on 10/16/2024 & 1/24/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Star Stevenson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815
VISIT DATE: 02/20/2025
NARRATIVE
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Continued from 809C

Civil penalties in the amount of $250.00 is being assessed due to repeat violations in the past 12 months for regulation  87303(a) previously cited on 10/16/2024 & 1/24/2025.

Civil penalties in the amount of $1,000.00 is being assess due to repeat violations in the past 12 months for regulation 87202(a) previously cited on 01/27/2025

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted with licensee/administrator
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/20/2025 02:13 PM - It Cannot Be Edited


Created By: Star Stevenson On 02/20/2025 at 12:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AMERICAN ASSISTED LIVING
FACILITY NUMBER: 486803815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2025
Section Cited
CCR
87705(j)

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87705(j) Care of Persons with Dementia. The licensee shall have an auditory device
or other staff alert feature to monitor exits, if exiting presents a hazard to any
resident. **This requirement is not met as evidenced by:
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Licensee agrees to submit self certification that exit door auditory devices are
activated and are functioning to CCL by POC 02/21/2025.
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Based on LPAs observations, the auditory devices in the patio/sunroom were not functioning which poses an immediate health and safety risk to residents in care.



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 Licensee agrees to conduct an all staff training with staff to review facility policy pertaining to auditory devices and
submit training roster and topics covered to CCL by POC 02/20/2028
Type B
02/28/2025
Section Cited
HSC1569.695(c)

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1569.695(c) Emergency Plans A facility shall conduct a drill at least quarterly ... The
type of emergency covered in a drill shall vary ...Documentation of the drills shall
include the date, the type of ...drill & the names of staff participating in the drill.
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Licensee agrees to conduct and document disaster drills every 3 months on all shifts
with all direct care staff. Licensee agrees to conduct a disaster drill on all shifts with
all direct care staff and submit proof to CCL by POC 02/20/2028
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This requirement was not met as evidenced by: Based on file review and interview,
the licensee did not conduct an emergency drill within the past quarter. This poses a
potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Star Stevenson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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